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Lower Extremity Blocks PDF
Lower Extremity Blocks PDF
Anatomy.
Male and female pelvis issue.
Lateral femoral cutaneous nerve block, anatomical technique.
Lateral femoral cutaneous nerve with ultrasound.
Femoral nerve block with nerve stimulation.
Femoral nerve block with ultrasound
Obturator nerve block with nerve stimulation..
Obturator nerve block with ultrasound.
Lumbar plexus block with nerve stimulation
Lumbar plexus block with ultrasound...
Sciatic nerve block, classic (Labat/Winnie)..
Sciatic nerve block, Francos 10-cm approach.
Sciatic nerve block midgluteal with ultrasound
Sciatic nerve block subgluteal, Di Benedettos approach.
Sciatic nerve block subgluteal, Francos 10-cm approach
Popliteal nerve block with nerve stimulation, Francos approach
Popliteal nerve block lateral approach with nerve stimulation.
Popliteal nerve block with ultrasound...
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The innervation of the lower extr emity comes from the lumbar and s acral plexuses. The
different nerve elements of the lower extremity run more distant from each other than those of
the upper extremity, never being confined to a sm all surface area like th e trunks of the brach ial
plexus do. Therefore, no single peripheral block tec hnique is able to provide anesthesia of the
whole lower extrem ity. This anato mical fact, combined with the high success of neuraxial
anesthesia, has traditionally affected the popularity of lower extremity peripheral nerve blocks.
The introduction of low molecular weight heparin in the United States in the early 1990s
with its increased risk for epidural hem atoma in association with neuraxial blocks produced a
renewed interest in lower extremity nerve blocks. The use of ultrasound in regional anesthesia
has also contributed to the increased popularity of all sort of peripheral nerve blocks.
Anatomy
Lateral femoral cutaneous nerve
It is an exclusively sensory nerve originating from the ventral ram i of spinal nerves L2L3. It appears in the pelvis, late ral to the psoas muscle, caudal to the ilioinguinal nerve. It runs
anteriorly under the iliac fascia, parallel to the iliac cr est. It emerges from the pelvis, under the
inguinal ligament, between the anterior superior a nd anterior inferior ili ac spines, as shown in
figure 7-1 and 7-2. It provides sensory innervation to the lateral thigh.
Femoral nerve
It is a motor and sensory nerve derived from the posterior divisions of the ventral rami of
spinal nerves L2-L3-L4. In the pelvis it is also located lateral to the psoas muscle, in the cleavage
between psoas and iliacus m uscles. As it passes under the inguinal ligam
ent the nerve is
superficial to the combined iliopsoas muscle. Under the inguinal ligament the femoral nerve has
the femoral artery m edial to it, followed by th e femoral vein m edial to the artery (VAN fro m
medial to lateral), as shown in figure 7-2.
Approximately 3-4 cm below the inguinal li gament, the fe moral nerve divides into
anterior and posterior divisions. The anterior division has tw o sensory branches that supply the
anteromedial thigh, and two m uscular branches that supply the sartorius and pectineus m uscles.
The posterior division has one sensory branch, th e saphenous nerve, and m uscular branches to
the quadriceps. The nerve is covered by the iliac fascia, which separates it from the main vessels,
and more superficially by the fascia lata, the deep fascia of the thigh.
The muscular branch to the rectus fem oris also supplies the hip join t while the muscular
branches to the three vasti muscles also supply the knee joint.
Obturator nerve
It is usually a mixed nerve (motor and sensory) derived from the anterior divisions of the
ventral rami of spinal nerves L2-L3-L4. It em erges on the m edial side of the psoas m uscle just
above the pelvic brim running down between this muscle and the lumbar vertebral column. As it
enters the pelvis it turns laterally to run al ong its lateral wall until it reaches the obturator
foramen, through which it enters the thigh. In the thigh the nerve divides into anterior and
posterior branches, as shown in figure 7-3.
The anterior division runs caudally, first located betw een the pectineus muscle in front
and the obturator externus behind. A few c m distally the nerve runs between the adductor longus
anteriorly and the adductor brevis posteriorly. It gives innervation to the gracilis, adductor brevis
and adductor longus, and som etimes to the pectineus. It gives also articula r branches to the hip
joint. On occasions it supplies the skin of the medial side of the thigh.
The posterior division after a short trajectory it usually pierces the obturator externus to
then run caudally between the adductor brevis in front of the adductor magnus behind. It supplies
the obturator externus, the adductor m agnus and the knee joint. The anteri or sensory branch can
be frequently missing and in that case the medial thigh is also supplied by the femoral nerve.
The highly variable distributi on of the cutaneous branch of the obturator nerve has
contributed to the confusion about how much anesthesia can be obtaine d from a single block
performed at the femoral level (3-in-1 block). Most of the stud ies have used pinprick of t he
medial, anterior and late ral thigh to test f or anesthesia of obturator, fem oral and lateral fe moral
cutaneous nerves respectively. This res ting does not tak e into account the fact that many
variations exist in the innervation patters of the thigh including the absence of a cutaneous
branch of obturator nerve. Nevertheless m any authors believe that a block at the fem oral level
could also produce anesthesia of the lateral fe moral cutaneous nerve by lateral diffusion of the
local anesthetic under the fascia iliaca (2 -in-1 block). Spread of lo cal anesthetic to the
obturator nerve either, m edially under the vessel s or proxim ally toward the pelvis is m ore
unlikely.
Sciatic nerve
It is the largest nerve in the body. It originates from the ventral rami of spinal nerves L4L5, S1-S3. Part of the anterior ramus of L4 jo
ins the ante rior ramus of L5 to origina te the
lumbosacral trunk, which together with the first th ree sacral roots form the sciatic nerve. The
nerve has two com ponents, the tib ial nerve (on its m edial side), which is derived from the
anterior divisions of the ventral rami of L4 -L5, S1-S3 and the common peroneal nerve (on its
lateral side), which is de rived from the posterior divisions of the ventral rami of L4-L5, S1-S2.
The nerve comes out of the pelvis through the greater sciatic foramen, entering the gluteal region
anterior (deep as seen from the gluteal region ) to the p iriformis muscle and cep halad to the
ischial tuberosity. After reaching th e lateral as pect of this bony promin ence, the nerve turn s
vertically downwards to run between the ischium medially and the greater trochanter laterally, as
shown in figure 7-4.
For most of its trajectory in the buttocks, the sciatic nerve runs parallel to the m idline, at
a distance of about 10 cm in adult patients. With the hips in adduction this distance is maintained
throughout adult life, not being influenced by gender or body weight. This previously unknown
fact has simplified enorm ously the approach to th e sciatic nerv e in our practice (for m ore
information see references 3 through 9).
The tibial and comm on peroneal com ponents can be easily identified as two separate
nerves during their entire trajectory in about 11% of the cases. However, even in those cases the
two components are surrounded by a common sheath of connective tissue as shown in figure 7-5.
Therefore, it is im portant not to confuse th is with a true separation of the com ponents,
which invariably takes place always in the popliteal fossa, as shown in figure 7-6.
The nerve enters th e thigh deep to the biceps f emoris muscle (and not later al to it as
usually mentioned in our literature), as shown in figure 7-7.
As opposed to what happen in the gluteal reg ion, the position of the sciatic nerv e in the
thigh with respect to the m idline is influenced both by the degree of hip abduction as well as by
the amount of fat accumulating in the inner thigh.
The nerve runs in the posterior thigh under th e cover of the ham string muscles, until it
reaches the popliteal fossa. Upon entering the popliteal fossa, the two nerve com
ponents,
peroneal and tibial, fin ally diverge from each other, hav ing never mixed their fibers. The
posterior tibial nerve continues to run in the direction of the main trunk, at the center of the fossa.
The common peroneal com ponent turns laterally to run just medial to the biceps tendon, as
shown in figure 7-6.
Subgluteal fold
The fold that defines the buttocks inferiorly is a fold of the skin and does not correspond
with the lower border of the gluteus maximus muscle, as frequently thought. In fact the inferior
border of this m uscle crosses the subgluteal fold diagonally as it r uns laterally to insert in the
iliotibial tract, as show n in figure 7-8. Therefor e, during a subgluteal a pproach to the sciatic
nerve, the n eedle crosses the sam e planes (fat and gluteus m aximus) than in m ore proximal
approaches, although the fat layer can be thinner.
Genitofemoral nerve
It derives from the ventral rami of spinal nerves L1-L2. Its genital branch provides some
of the innervation of the genital area, while its femoral component provides sensory innervation
of the medial upper thigh and the skin over the femoral vessels.
Posterior cutaneous nerve of the thigh
It is also known as posterior fem oral cutaneous nerve. It originates from the ventral rami
of spinal nerves S1-S3. It exits the pelvis th rough the greater sciatic fo ramen, first medial and
then superficial to the sciatic nerve. Somewhere caudal to the ischium, the nerve pierces the deep
fascia (fascia lata) and becom es a superficial structure. It is not a branch of the sciatic nerve,
although it has a close relationship w ith it in the gluteal area, as shown in figures 7-9 and 7-10,
before it becomes a superficial nerve as shown in figure 7-11.
nerve
sciatic
of the
by Dr
It innervates the lower part of the buttock s as well as the posteri or thigh, frequently
reaching down as far down as the proxim al posterior aspect of the leg. A block of the sciatic
nerve performed in the gluteal area will predictably produce anesthesia of this cutaneous nerve as
well. A block performed at the subgluteal level on the other hand, will not reliably block it.
Saphenous nerve
It is a sensory nerve that originates from the posterior division of the femoral nerve (L3L4) in the inguinal region. It is the largest cutaneous br anch of the fem oral nerve. It runs down
the femoral canal along with the fem oral vessels, under the cover of the sartorius m uscle. It
emerges on the medial side of the knee between the tendons of sartorius and gracilis, as shown in
figure 7-12
At a variable distance caudal to the knee, it p ierces the deep fascia to become superficial.
Distal to the knee it gives off the subpatellar branch, which supp lies the medial side of the knee
(chance for injury during knee arthroscopy). Once it becomes superficial, it runs alongside the
greater saphenous vein in the le g, passing in front of the m edial malleolus in the ankle, before
terminating around the base of the first metatarsal on the medial side of the foot.
The nerves of the lower extrem ity are more distant from each other than in the upper
extremity so it is not possible to block the e ntire lower extremity from a sing le
injection point.
The position of the sciatic nerve in the buttocks with respect to the midline is dictated
by the bony pelvis and as such it not affected by gender or obesity. Its relationship to
bone structures and to the midline remains unchanged throughout adulthood.
The inferior border of the gluteus m aximus muscle does not correspond with the
subgluteal fold (Snells Clinical Anatomy for Medical Students, 3 rd edition, page
554). In fact both cross each other diagonally. The subgluteal fold is a fold of the skin
anchored to the deep fascia.
The gluteus maximus is the on ly gluteal muscle to cover the scia
tic nerve
superficially, caudal to the pirif ormis muscle. Gluteus medius and m inimus are
located cephalad and lateral to the sciatic nerve.
The inguinal crease does not co rrespond with the inguinal lig ament. Both structures
are parallel to each other. The inguinal crea se runs about 1 inch (2.5 cm ) caudal and
parallel to the inguinal ligament.
Fig
7-13. Lateral femoral
cutaneous nerve and ASIS. As the
nerve, shown with arrows, enters
the thigh medial to the anterior
superior iliac sp ine (ASIS) and
deep to the fascia lata.
(Authors archive).
A few c m distal to the inguinal ligam ent the nerve, still under the fascia lata, can be
observed causing a sm all indentation on th e anterolateral surface of the sartorius, as shown in
figure 7-14.
Type of needle
A 5 cm, 22G, insulated needle usually suffices.
Nerve stimulator settings
The nerve stimulator is set to deliver a 1.0 mA current, at a frequency of 1 Hz and pulse
duration of 0.1 msec (100 microsec).
Needle insertion
The needle is inser ted 1-2 cm lateral to the pulsa tion of the femoral artery with a 30-45degree cephalad orientation, as shown in figure 7-16 a and b.
The needle is advanced parallel to the midline in the direction of the inguinal ligament. A
twitch of the quadriceps m uscle with movement of the patella is a good response. T he current is
lowered and with a m uscle twitch still visible at 0.5 mA a slow injection is started. A response
from the sartorius is usually considered not a good response, because it could be th e result of
stimulation of the nerve to the sartorius, a branch of the anterior division of the femoral nerve. If
the block is performed 1 cm above the inguinal crease where the nerve has not branched off yet,
a twitch from the sartorius is equally acceptable.
Local anesthetic and volume
The femoral nerve is a collection of branches flat in the frontal plan e that offers a large
area of ab sorption. Usually we u se at th is location 10-15 mL of local an esthetic solution. For
anesthesia we usually use 1.5 % mepivacaine plus 1 :400,000 epinephrine for 3 -4 hours of
surgical anesthesia. For longer anesthesia 0.5% r opivacaine or bupivacaine can be used alone or
in combination with mepivacaine. For analgesia we usually use 10-15 mL of 0.2% ropivacaine.
We always use epinephrine 1:400,000 as an intravascular marker.
Side effects and complications
Blocks at the femoral level are usually well tolerated and complications are rare.
If possible we like to p lace the probe parallel and immediately (1 cm ) above the crease.
At this location, abov e the crease and below th e inguinal ligament, the m ultiple branches that
form the femoral nerve are clo sely together forming a more compact structure. The femoral vein
is the most medial structure of the neurovasc ular bundle and is easily collapsible by the probe.
The artery is situa ted lateral to the vein and th e femoral nerve is loc ated lateral to the arte ry.
There can be a gap of about 1 cm in between the artery and the nerve.
Needle insertion
The needle can be advanced in plane, from lateral to medial, as shown in figure 7-19, or
out of plane caudal to proximal, as shown in figure 7-20.
The multiple branches that constitu te this nerve provide an a mple area of absorption for
the local anesthetic. Usually we use 10-15 mL of local anesthetic solution. For anesthesia we use
1.5% mepivacaine plus 1:400,000 epinephrine, alone or in combination with 0.5% ropivacaine or
bupivacaine. For analgesia 0.2% ropivacaine is our drug of choice.
Side effects and complications
Very rare. He matomas from puncture of the femoral artery are possible, but avoidable
with meticulous technique, use of s mall gauge needles and thorough compression of the arterial
puncture when it occurs. The use of ultrasound almost eliminates this problem.
Type of needle
Depending on the patient, a 5cm or 10cm insulated needle is used.
Nerve stimulator setting
The nerve stimulator is set to deliver a 1.0 mA current, at a frequency of 1 Hz and
pulse duration of 0.1 msec (100 microsec).
Needle insertion
The needle is inserted alm ost perpendicular to the frontal p lane with a slight cepha lad
angulation, as shown in figure 7-22.
As the needle trav erses the muscular plane, a localized twitch from the pectineus and or
adductor longus is usually elicite d by direct m uscle stimulation. As the needle reaches the deep
face of the muscle and the proxim ity of the obturat or nerve a m ore global twitch of the thigh in
adduction is obtained. At this point the current is lowered progressively to around 0.5 mA, and if
a twitch is still visible, a slow injection is st arted. If the needle m akes contact with the pubis
ramus, it is walked off caudally.
Local anesthetic and volume
A volume of 10-15 mL of local anesthetic is usually used. Mepivacaine 1.5% can be used
with 1:400,000 epinephrine for 3-4 hr of anesthes ia. For longer anesthesia 0.5% ropivacaine or
bupivacaine can be used. For analgesia 0.2% ropivacaine is commonly used.
Complications
Hematoma is the most frequent complication of this technique. Adductor m uscles spasm
can occur.
This way the determination of the location of the obturator nerve is framed between two
easily identifiable structures, the femoral vessels on the lateral side and the m edial border of the
adductor longus on the medial side. The probe is placed parallel and slightly above the inguin al
crease over the femoral vessels and then tra ced medially until it rests over the pectineus muscle,
as shown in figure 7-24.
With the pr obe over th e pectineus muscle the obturator nerve can be seen as a m ostly
hyperechogenic ovoid image under the pectineus muscle, as shown in figure 7-25.
If the scan ning instead is performed a few centim eters more distally th en the two
branches of the obturator can be seen, as shown in figure 7-26.
Needle insertion
My preferred method for this pa rticular block is to use and out of plane technique from
distal to proximal, as shown in figure 7-27.
Type of needle
At least a 10cm, 21-G, insulated needle is necessary for this block.
Nerve stimulator settings
The nerve stimulator is set to deliver a curre nt of 1.5 m A, at a pulse frequency of 1 Hz
and pulse duration of 0.1 msec (100 microsec).
Needle insertion
The needle is inserted parallel to the m idline at the junction between the lateral third and
middle third of the line joining th e midline with the level of the posterior superior iliac spine, as
shown in figure 7-29.
This insertion is m ore medial than the or iginal technique. It is based on a study by
Capdevila et al in 2002 in which they showed that a needle inserted at the level of the PSIS falls
lateral to the plexus making it necessary to reposition it medially and pot entially increasing the
risk for epidural or spinal injection.
As the needle is inserted through the mass of the paraspinal muscles a local contraction is
usually observed. The transverse process of L4 or the nerves of the lu mbar plexus should be
contacted within 3 cm from the disappearance of the local back muscles twitch. If not, the needle
is withdrawn superficially and re directed caudally or cephalad. If the transverse process (usually
L4) is conta cted the ne edle should be walked off caudally until a quad twitch is obtained, not
deeper than 2 cm from the transverse process. If no response is obtained within 2 cm the needle
can be redirected cephalad from the transverse process and again advanced for up to 2 cm.
When a m uscle twitch f rom the quad is obtain ed the cu rrent in th e nerve stimulator is
decreased to around 0.5-0.8 m A and with a visible response a gentle aspiration is performed for
blood or C SF before injecting a test dose am
ount of 3-5 m L of local anesthetic with
epinephrine 1:200,000. If no intravascular or subarachno id injection is detect ed the rest of the
local anesthetic volume is slowly injected in small increments with frequent gentle aspirations.
The preferred response in this block is quad response. An obturator response could m ean
that the needle is too medial and should be redirected slightly lateral.
Based on this information the operator needs only to identif y the psoas muscle anteriorly
and the tran sverse process of lower lum bar vertebras posteriorly (where the quadratus inserts)
and deposit the local anesthetic in between the two without the need to penetrate the substance of
the psoas muscle.
Figure 7-31 shows a schematic representation of the posterior abdominal wall and lumbar
plexus branches.
In order to visualize the quadratus lum borum and psoas muscle with ultrasound the
operator needs to take advantage of the sm all spaces or acoustic windows located between the
bone structures of the lumbar spine.
Figures 7-32; 7-33 and 7-34 represent a sequen ce of i mages obtained with the pro be in
the transverse position, across the lower lumbar spine.
accepted but it m ight have som e problems of its own. Because, as discussed in the anatom y
section, the transverse diam eter of the pelvis is fairly constant in all adults, any prolongation of
the perpendicular line would bring it closer to the m idline (its direction is caudal and medial).
This will mean that a tall patien t with a long sacrum will have a sciatic nerve located closer to
the midline (long perpendicular li ne) than a short patient. T his obviously could not be the case.
The fact is that the perpendicular line of Labat was not created to be flexible in length.
The combined classic approach (Labat-Winnie), despite its shortcom ings, is the most
commonly used posterior approach to the sciatic nerve in the gluteal area.
Technique
Usually the block can be com pleted with a 4, insulated needle, but sometim es a longer
needle needs to be used. The needle is advanced , perpendicular to all pla nes until a twitch f rom
the sciatic nerve is foun d. If a twitch is still vi sible at 0.5 mA a slow in jection is started with
frequent aspirations. If the nerve is not contacted, the technique does not have a clear strategy for
reposition of the needle. In fact the nerve could be at any point around a 360-degree radius.
Local anesthetic and volume
For anesthesia 1.5% m epivacaine plus 1:400,000 epinephrine in a volum e of 30-35 mL
can provide 3-4 hrs of anesthes ia. Ropivacaine 0.5-0.75% with epinephrine or 0.5% bupivacaine
with epinephrine can be used if longer duration is needed.
Complications
The literature mentions that the ab sorption from this site is m inimal. However, it is
important to remember that the branches of the inferior gluteal vessels at this level are large and
multiple, therefore hematomas could develop. The patient lying supine immediately post block
could theoretically help to decrease the chance for a hematoma to develop.
It is im portant to inject slowly,
alternated with f requent and gentle asp irations.
Dysesthesias in the ter ritories of the sciatic or posterior femoral cutaneous nerves are reported
more frequently after this block than any other. These problem s usually resolve within 1-2
weeks.
When the n eedle reaches the glu teus maximus muscle a local m uscular twitch of the
buttock is observed. This twitch is very reassuri ng, telling the operator that the needle-stimulator
unit is functional and most im portantly, providing information on sciatic nerve depth. If 8 cm or
more, of a 10 cm needle, have been used to reach the gluteus maximus, it is unlikely that the
needle will be long enough to reach the sciatic nerve.
The needle is advanced through the gluteus m uscle, with a visible local twitch that does
not disappear until th e needle reaches beyond th e deep surface of this m uscle. The ensuing
silence is evidence th at the needle is passing through the connective tissue that separates the
gluteus maximus from the nerve. It shou ld be soon followed by a twitch
resulting from
stimulation of the scia tic nerve. Th e nerve is rarely more than 2 cm deeper to the gluteu s
maximus.
I believe that any of the possible respon
ses from the sciatic nerve (i.e. eversion,
dorsiflexion, inversion and plantar flexion) are adequate, provided that the injection is made with
a visible response at 0.5 mA or less. There are few reports in the literature that arg ue in favor of
inversion and against eversion. This is not our experience.
If no response from the sciatic nerve is obtained deeper to the gluteus maximus, then a
reposition of the needle is necessary. Here is very important to take in to account the vector
effect, the impact of the angle of reinsertion in the final position of the needle. According to m y
own calculations, at a th eoretical depth of 9 cm, a 10-degree correction angle, moves the needle
tip 1.6 cm, while a 20 -degree correction moves it 3.4 cm. Because the nerve is around 1.5 cm
wide, it would be very easy to overshoot the correction.
Some useful tips when trying to pinpoint the sciatic nerve
When an adequate twitch is found, t he nerve stimulator current is lowered until a twitch
is still visible at 0.5 m A or less. This is done while m aintaining visual contact with the twitch. If
the twitch becomes too weak, before reaching 0.5 mA, the current is not lowered any further and
instead the operator slowly moves the needle closer to the nerve.
It is not infrequent to see the response fade as th e needle is inserted deeper. This can be
the result of a needle approaching the nerve tangentially, along one of the sides of the nerve. We
usually try to perform a small correction in order to get a bulls eye alignment with the nerve.
Deciding whether to correct lateral or medial depends on what type of response is being elicited.
Eversion and dorsiflexion are resp onses from the comm on peroneal nerve (lateral side), while
inversion and plantar flexion ar e responses from the tibial nerve (m edial side). A sm all
correction is then made accordingly. A more co ntrolled correction can be accomplished by only
partially removing the needle a couple of cm. The unburied portion of the needle is then bent and
directed in the desired direct ion. The buried portion of the needle keeps the needle from
overcorrecting. Bringing the needle out com pletely, and then reinse rting it, carries a chance of
overshooting the correction.
Complications
Same as classic approach.
Pearls
The 10 cm m easurement is a lin ear measurement that disregards, o n purpose, the
patients buttock contour. This lin ear measurement tries to ref lect only the distance
between the midline and the outer lip of the ischium, without soft tissue interference.
Placing the patient in true lateral position, m akes the patients m idline parallel to the
table. If this position is not
possible, the operator needs to as certain the degree of
inclination of the midline with respect to the table, so the needle still may be adv anced
parallel to the patients midline.
When the nerve is not found at first attem pt, it could only be locate d either lateral or
medial to the needle. Because of gravity, it is more frequent to underestimate the midlinenerve distance (sagging midline). Therefore, the first correction should be lateral.
When reposition is necessary, keep in mind the vector effect. At a th eoretical distance
of 9 cm a 10-degree correction will move th e needle app 1.6 cm . A 20-degree correction
will move it 3.4 cm . This big jum p could easily overshoot the correction. A sm all 10degree correction usually is all it takes to localize the nerve.
Needle insertion
The easiest approach is to in troduce the needle out of plane from distal to proxim al as
observed in figure 7-39.
Figure 7-40 shows an ultrasound image of an out of plane technique after injection.
Technique
The authors advice inserting the needle perpendicular to the skin until a twitch f rom the
sciatic nerve is obtained.
Local anesthetic and volume
The same than for classic approach
Complications
Common to other approaches to the sciatic nerve.
The subgluteal approach can be easily perf ormed at 10 cm from the m idline at the
subgluteal fold, with the patient lying in lateral decubitus, as shown in fig 7-41.
The 10cm measurement is made lateral to the midline at the level of the subgluteal
fold, in a way similar to the one described for the midgluteal approach. The needle is
advanced parallel to the midline, through the gluteus maximus muscle and into the sciatic
nerve. The current is lowered to around 0.5 mA and a slow injection is started. If the nerve is
missed at first pass it could only be located medial or lateral to the needle. The needle is
reinserted, with a small 10degree correction in its orientation, first lateral (toward the
trochanter) and then medial (to the midline) if necessary.
Ultrasound technique
Although the same tissue layers cover the sciatic nerve at the midgluteal and subgluteal
levels, the fat layer is usually thinner. This makes the ultrasound visualization of the sciatic nerve
at this level usually easier than in the midgluteal area. Depending on depth, the nerve can be
visualized with a linear high frequency probe, but frequently a lower frequency probe is needed.
Curved low frequency probes are needed for bigger patients. The patient is placed prone, lateral
position or Sims position. The nerve is visualized in cross section (short axis) and the needle is
advanced either out of plane (usually) or in line with the probe.
A few facts on subgluteal approach
1. This approach consistently misses the posterior femoral cutaneous nerve, so anesthesia of
the back of the thigh is only obtained in
about 30% of the cases (our own data, Reg
Anesth Pain Med, 2006). The reason is that th e posterior femoral nerve is usually already
a superficial nerve (above the fascia) at the level of the subgluteal fold.
2. The inferior border of gluteus m aximus and subgluteal fold are not the sam e thing.
Therefore, during a subgluteal approach the needle needs to pass through the sam e layers
of tissue than at more proximal approaches.
3. The sciatic nerve is relatively m ore superficial at the subgluteal fold because the am ount
of fat decreases from m id-gluteal to subgluteal level, although the type of layers (fat and
muscle) remains the same.
4. The popliteal fossa is the only lev el in the tra jectory of the scia tic nerve in which the
nerve is not covered superfic ially by m uscle. Approaching the sciatic nerve, without
passing through muscle is the only true advantage of a popliteal approach.
5. In terms of anesthesia distribution, the subgl uteal approach is m ore comparable to the
popliteal block than to other more proximal approaches.
The distance between these two points in adults is usually 6-7 cm in fe males and 7-8 cm
in males. The midpoint between the two tendons is located and marked, as shown in figure 7-43.
44.
The needle insertion point is then found 7-9 cm above the crease, as shown in figure 7-
Type of needle
A 5cm, 22-G, insulated needle is usually adequate.
Nerve stimulator settings
The nerve stim ulator is set to deliver a current of 1.0 mA (h igher in diabetics) with a
pulse frequency of 1 Hz and pulse duration of 0.1 msec (100 microsec).
Needle insertion
The needle is introduced with a 30-45 degree cephalad orie ntation, as shown in figure 745.
The needle is directed approxim ately 45-degrees cephalad, so the conta ct with the nerve
happens at 1-2 cm higher from the crease than th e actual entrance poin t, increasing the chances
that the sciatic nerve is contac ted prior to its division. T he distance at which the needle is
inserted varies acco rding to the patients heigh t. A good ballpark estim ation is to insert th e
needle at a distance from the crease that is 1 cm longer than the inter tendinous distance.
Once a response from the sciatic nerve is elicited, and still present at 0.5 m A or less, a
slow injection is started with frequent aspirations.
Local anesthetic and volume
I believe that a block of the sciatic nerve in the popliteal fossa using nerve stim ulation
requires a higher volum e than more proximal approaches. As a general rule I give about 10 m L
more of local anesthetic solution than what I w ould give to the sam e patient at m ore proximal
locations. This comes to about 35-45 mL of 1.5% mepivacaine with 1:400,000 epinephrine for 34 hr of anesthesia. If longer anesthesia is desired I would use a combination of 1.5% mepivacaine
with epinephrine followed by 0.5% ropivacaine or bupivacaine plus epinephrine.
Complications
Small hematoma can develop. Residual dysesthesias lasting up to two weeks can be seen.
POPLITEAL BLOCK
ULTRASOUND TECHNIQUE
Indications
The same indications than nerve stimulation techniques.
Patient position
There are basically two main positions in which this block can be perform ed, supine and
prone. The views obtained are sim ilar, but in general the supine technique can be m
ore
challenging, especially in larger patients. The supine technique involves an in plane lateral
approach, while the prone technique provides the opportunity for out of plane approaches also.
Whether the technique is done su pine or prone, havi ng the patient flex the knee im proves the
visualization of the sciatic nerve and its components.
Type of needle
If an out of plane technique is perform ed usually a 22-G, 5cm, insulated needle suffices.
If an in plane lateral approach is attem pted usually a longer 10cm , 21-G, insulated needle is
needed.
Type of transducer
In most cases a linear, high frequency (8-1 5 MHz) is used. In la
sometimes necessary to use a curved, low frequency (3-7 MHz) probe.
rger patients it is
Scanning
The nerve is scanned in short axis. The sc
anning can be started at any level in the
popliteal fossa but it is helpful to start at the crease where the popliteal vessels, vein and artery,
have an intimate relationship with the tibial co mponent of the sciatic nerve. Figures 7-46 A-D
show a sequence of images as the probe is moved from distal to proximal.
Needle insertion
The needle can be inserted out of p lane, usually from distal to proximal or in plane f rom
lateral to medial, as shown in figure 7-47.
A needle inserted in pla ne from the lateral side is easily seen in the screen as sho wn in
figure 7-48.
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